Eye care in primary care

Healthy eyes are essential to wellbeing throughout the lifespan, and primary care clinicians are key players in ensuring patients have continued eye health from birth to age 100 (or more). Two experts provided advice on eye health: Dr. John Lloyd, staff ophthalmologist at Sunnybrook Health Sciences Centre in Toronto, and Dr. Christine Richardson, an emergency physician with London Health Sciences Centre and associate professor at Western University in London, Ont. Dr. Richardson practised as an optometrist prior to entering medical school. Common eye conditions Common conditions seen in the primary care clinic include conjunctivitis, and family physicians need to know the difference between bacterial, viral or allergic conjunctivitis and prescribe appropriately. “I find there tends to be an overuse of antibiotic drops for conjunctivitis,” Dr. Richardson said, noting that she understands it often takes more time to counsel patients why they don’t need antibiotics than to give antibiotics. While most cases are viral, and antibiotics aren’t indicated, if the patient wears contact lenses, err on the side of caution and prescribe antibiotics because there’s a higher risk of pseudomonas keratitis, she said. Simple blepharitis, or inflammation of the eyelid margin, can be treated in primary care with straightforward hot compresses. “Family doctors can also recommend that patients use any kind of over-the-counter pre-made lid scrub solution or even a bit of diluted Johnson & Johnson baby shampoo because it is not irritating to the eye itself,” Dr. Richardson said. Advise the patient to use a cotton swab or a bit of gauze to do a lid scrub once a day along with hot compresses a couple of times a day, she said. Hot compresses a few times a day also remains the main treatment for styes. If a stye isn’t resolving, switch to an antibiotic ointment, such as erythromycin, Dr. Richardson said. A chalazion, which is a deeper and more tenacious infection, can also be treated with compresses in the early stages, but will require a referral to an ophthalmologist. “Persistent chalazion ultimately all need outpatient referral. There’s not typically any urgency with it but sometimes we require more definitive management with the ophthalmologist,” Dr. Richardson said. Family physicians should be able to recognize a number of common eye conditions, such as subconjunctival hemorrhage and know the difference between preseptal versus orbital cellulitis. References family physicians can use to recognize common eye conditions (think subconjunctival hemorrhage or preseptal versus orbital cellulitis) include the Wills Eye Book or the Toronto Guide to Clinical Ophthalmology. The College of Family Physicians of Canada (CFPC) and the American Academy of Family Physicians have CME on eye health. Dr. Richardson and Dr. Simon Moore, a family physician and clinical associate professor at the University of British Columbia, did a review of common eye conditions for the CFPC, available on YouTube. Dry eye Many patients experience chronic dry eyes, either through the aging process or following laser refractive surgery. These patients will complain of irritated eyes that feel sandy or that feel like there’s a foreign body in their eye. Patients may say their eyes feel tired, especially after reading or spending time in front of the computer. For the most part, dry eyes can be managed with over-the-counter eye drops, gels or ointments, Drs. Richardson and Lloyd said. For eye drops, Dr. Richardson said she’s a fan of Systane, preferably the preservative-free formulation, Systane Complete. Dr. Lloyd said physicians should not recommend Visine for a chronic condition such as dry eyes. “Almost anything else is acceptable,” he said, including Visine’s artificial tears product Visine Advance True Tears. He also recommended Refresh, and preservative-free formulations from Hylo and HydraSense. “One of the most important things for people to do is to have some sort of lubrication before they go to bed, and that’s when I get into for more of a gel consistency,” Dr. Richardson said. This includes Refresh Lacri-lube or Bausch and Lomb Tear-Gel. Prescription drops should be left to ophthalmologists, Dr. Lloyd said. Steroid-containing eye drops can worsen some conditions such as herpetic keratitis and corneal ulcers and long-term use can cause cataracts and glaucoma, he wrote in a 2011 Canadian Medical Association Journal (CMAJ) review paper on red eyes. Another option to offer for dry eyes is vitamin or mineral supplements. “There are some supplements that are fairly harmless, including omega-3 supplements,” Dr. Lloyd said, adding that the evidence supporting the supplements is weak but they were found to be of some benefit. “One of the most important things for people to do is to have some sort of lubrication before they go to bed, and that’s when I get into for more of a gel consistency.” Red flags Three red flags when seeing patients for an eye condition are a loss of vision acuity, eye pain and anisocoria or uneven pupil sizes, Dr. Moore said in the CFPC video. A careful line of questioning can help physicians understand the nature of the eye condition, especially when a patient is complaining of pain. “When you’re asking about the pain component, is it a scratchy, superficial pain, or do they have an achiness or headache or significant photophobia? If that were the case, then I’m going to be worrying more about things like iritis or uveitis. As family physicians or primary care physicians we certainly can’t manage those,” Dr. Richardson said. When examining patients, consider the possibility of acute glaucoma, corneal ulcers or retinal detachment. Start the examination by checking visual acuity, the pupils reflex to light, and use a penlight or slit lamp to examine the anterior segment of the eye, Dr. Lloyd wrote in the CMAJ paper. Fluorescein dye will highlight a corneal ulcer or corneal abrasion. Some cases of foreign bodies lodged in eyes can be handled in primary care, especially if it is superficial, but know when to send a patient to an optometrist or to the emergency room. “The role of the family doctor is to be able to triage who should be seen more urgently,” Dr. Lloyd said. For example, if a patient has an acute symptomatic onset of a large number of floaters associated with flashing lights and a visual field defect (symptoms of retinal detachment), they should be seen within 24 hours. Someone with a few floating specks only needs to be seen in a few weeks. Dr. Lloyd noted that it’s helpful when family physicians provide information on the seriousness or urgency of the case they are referring. For example, a referral due to cataracts should specify if the patient can’t see the big letter E on the Snellen eye chart or if they have almost normal vision. Many ophthalmologist offices will ask for patients to have an optometric eye test first in order to triage the urgency of the referral. Ask about prior surgery If a patient presents with an eye injury, always ask if they had prior LASIK surgery, Dr. Lloyd stressed. Ask all patients this, even those with simple corneal abrasions. If they had LASIK surgery in the past, they need to see their LASIK surgeon within one to two days. If they had their LASIK outside of Canada, “call any LASIK centre nearby and they generally will be willing to assess the patient,” Dr. Lloyd said. “If you get a corneal abrasion in the presence of LASIK, it can be a much more serious issue,” Dr. Lloyd explained. The flap can move and be damaged in a number of ways. Any complications or concerns following any eye surgery should be treated by the surgeon, both Drs. Lloyd and Richardson said. This is especially true if there’s pain. Eye health through lifespan Children should be screened for eye problems in primary care starting at birth. They should also see an optometrist at an early age. Guidelines from the Canadian Association of Optometrists and the Canadian Ophthalmological Society suggest that children have a full eye exam around age three, or at least before entering the school system. This is to detect strabismus, amblyopia and other eye conditions that present before age five. As people age, they should continue to be seen by an optometrist. “As family docs we can advocate that patients get routine eye care at least every three to five years,” Dr. Richardson said. Patients with diabetes need to have an examination every year. As patients get older, more frequent screening is needed as the risk of macular degeneration and cataracts increases. Glaucoma can also develop undetected and can progress into vision loss if untreated. “Over the years I’ve had many patients have loss of vision in one eye but they don’t notice it until they happen to cover their other eye for some reason,” Dr. Lloyd said. “They often show up in the emergency room with an advanced cataract that obviously didn’t happen suddenly, but they didn’t notice.”

Eye care in primary care

Register for free access or login.

Related Topics